Does my child have a mental disorder?

The question is difficult, even frightening, for a parent to voice.  Understandably, it is easier to overlook or explain away subtle signs of illness that may occur periodically at worst and are set against the rapid changes of childhood or the turmoil of adolescence.  “It’s just a phase.” “He’ll grow out of it.” “She’s under a lot of stress.” “We need to assure him that we love him.” “No one in our family has a mental illness.”  Yet the concern that sparks a parent’s question may be justified.  One in five American children and adolescents has a mental or behavioral disorder that interferes with their ability to learn in school or to establish healthy relationships with family members and friends. For one in 10 youngsters, a mental disorder will lead to moderate to severe impairment in one or more facets of their life.

What Causes Childhood Depression?

No single cause of depression has been identified. However, we know that depression is an illness with a pronounced biological basis. The genes that we inherit, and which continue to be influenced by experience throughout life, may predispose a person to the illness, but this predisposition, or vulnerability, to depression typically is “triggered” by life events.

Researchers have begun to identify these triggers, called risk factors, for depression.

A child’s risk for becoming depressed may increase with stress or with an experience of devastating loss or trauma. Behavioral problems and mental disorders – for example, conduct, attention-deficit, learning, anxiety, and substance abuse disorders — frequently co-occur with depression and may help explain its onset. A family history of depression or bipolar disorder is a significant risk factor for depression in a child or young adult.

Depression may – and frequently does – occur when no member of a family has knowingly experienced a serious mental disorder.  The underlying biological mechanisms and triggering events for illness in these instances have yet to be clearly understood.  

What can be said with surety is that in children no less than in adults, clinical depression is not a character weakness, normal sadness, or a passing phase. It is a real medical illness that can be accurately diagnosed and effectively treated.  Indeed, a child’s response to appropriate treatments is a valuable way of validating the presence of the disorder.

What is the Risk of Suicide?

Suicide frequently is a direct and lethal outcome of depression.  When a teenager thinks or talks about suicide, the risk is real.  Children should understand that if a sibling or friend discusses suicide, it should be called to the attention of an adult. A suicidal gesture should not be viewed as attention getting, but as an anguished cry for help.

The mid-1960s marked the start of an alarming, three-decade long increase in rates of suicide by young white males, a tragic incline that has been followed more recently by young black males. Each year in the U.S., almost twice as many adolescents commit suicide as die from all natural causes combined. Not even pre-teens are immune.

A recent down-turn in rates of adolescent suicide may reflect increasing widespread use of safer and more effective medications to treat depression. Suicide remains a public health crisis, however, that demands research to improve preventive strategies.  

How Can We Recognize Depression?

Extensive research has identified the signs and symptoms of major depression. In children, doctors are learning, these classic symptoms often may be obscured by other behavioral and physical complaints – features such as those bracketed. At least five symptoms must be present to the extent that they interfere with daily functioning over a minimal period of two weeks.

Signs and Symptoms of Depression
(As seen often in children and adolescents):  

• Frequent sadness, tearfulness, crying
• Increased irritability, anger, or hostility
• Hopelessness 
• Preoccupation with nihilistic song lyrics
• Decreased interest or enjoyment in once-favorite activities
• Low energy
• Persistent boredom
• Frequent complaints of physical illness; for example, headache, stomachache
• Poor communication with family and friends, social isolation
• Low self-esteem, feelings of guilt
• Oppositional; negative
• Extreme sensitivity to rejection or failure
• Inability to concentrate (poor performance in school; frequent absences)
• Changes in sleep habits (Excessive late-night TV; refusal to wake in the morning)
• Changes in eating habits (Failure to gain weight as normally expected; bulimia or anorexia)
• Talk of running away from home or efforts to do so
• Thoughts or expressions of suicide or self-destructive behavior

What Can We Expect From Treatment?

Treatments for depression are well-defined and effective for the vast majority of those with the illness.  Teachers, or a pediatrician or other health care provider, often are the first to put a name to the changes in a child’s behavior that are seen with depression. Your child’s doctor can rule out the presence of general medical illnesses that might present with some depressive symptoms and, in some instances, may be willing and capable of treating depression. Often, however, seeking specialty care is advisable.

A mental health professional can verify a suspected diagnosis and help a parent and child understand the array and benefits of different treatment options.

Ideally, a treatment program will combine psychotherapy and medications. The former relies on age-appropriate communication as a tool for bringing about changes in a patient’s feelings or behavior. While different types of therapies tend to be offered in various communities, research has shown that “here and now” approaches that concentrate on solving problems (rather than on gaining insight into psychological processes) are preferable. 

Two specific forms of therapy, cognitive behavioral therapy, and interpersonal therapy, have now have been validated by research to be effective in treating depression in youth.

Parents should be encouraged to ask a therapist specific questions up front: for example, how frequently and over what period of time will therapy take place; whether sessions will involve the depressed child alone, or others in the family also; and how the therapist will assure confidentiality to a child or teenager without locking parents out of the process.

Antidepressant medications target chemical imbalances in the brain that are associated with depression. Several antidepressants introduced in recent years have little potential risk for dangerous overdosing or adverse effects, and are quite effective in adults. Recent studies indicate that these medications can be useful in treating youth depression as well. Additional studies are ongoing in order to further define the efficacy of these medications in children and adolescents.

Parents should ask the physician for details about the purpose of a medication; how long it will take to exert therapeutic action; the frequency with which the physician will evaluate the effects of the treatment and need for dosage changes; and any precautions (for example regarding diet, exercise, side effects) to keep in mind. The child or teen patient should also have age-appropriate information about the medications.

Finding a Mental Health Care Clinician

A child’s pediatrician or other primary health care provider as well as school teachers and counselors are key sources for potentially recognizing mental disorders in children and adolescents. With input and support from a child psychiatrist or child psychologist, primary care providers may treat depression, particularly given the availability of increasingly safe anti-depressant medications. But for primary care physicians, especially, time needed to talk to a child and adolescent and his or her family often is limited. Likewise, a specialist’s (e.g., a child psychiatrist) input and guidance on medication issues may be needed.

If referral to a mental health specialist is sought, psychiatrists, psychiatric nurses, psychologists, and psychiatric social workers all are qualified to provide mental health care to the extent that they are licensed, or certified. Only psychiatrists, who are physicians, can prescribe medications, however. Ideally, the mental health specialist should be trained to work with children and adolescents. 

In 2004, after a thorough review of data, the Food and Drug Administration (FDA) adopted a "black box" warning label on all antidepressant medications to alert the public about the potential increased risk of suicidal thinking or attempts in children and adolescents taking antidepressants. In 2007, the agency extended the warning to include young adults up to age 25. A "black box" warning is the most serious type of warning on prescription drug labeling. The warning emphasizes that children, adolescents and young adults taking antidepressants should be closely monitored, especially during the initial weeks of treatment, for any worsening depression, suicidal thinking or behavior, or any unusual changes in behavior such as sleeplessness, agitation, or withdrawal from normal social situations.